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Physicians' Preferences for Hospice If They Were Terminally Ill and The Letters in 5.6% and 0.36%, respectively, only marginally less than the 6. Vakil N, Moayyedi P, Fennerty MB, Talley NJ. Limited value of alarm features prevalence in those with symptomatic GERD.7 in the diagnosis of upper gastrointestinal malignancy: systematic review and meta-analysis. Gastroenterology. 2006;131(2):390-401. The difficulty in identifying the right patients with GERD 7. Rex DK, Cummings OW, Shaw M, et al. Screening for Barrett’s esophagus in to endoscope is demonstrated in the study by Kramer et al,8 colonoscopy patients with and without heartburn. Gastroenterology. published in this issue. In an impressive audit of nearly 500 000 2003;125(6):1670-1677. cases of GERD identified in Veteran Health Administration rec- 8. Kramer JR, Shakhatreh MH, Naik AD, Duan Z, El-Serag HB. Use and yield of ords, the authors found that those patients more likely to re- endoscopy in patients with uncomplicated gastroesophageal reflux disorder ceive an EGD in the first year after diagnosis were actually less [published online January 27, 2014]. JAMA Intern Med. doi:10.1001/ jamainternmed.2013.12756. likely to have either BE or esophageal cancer.8 Men older than 9. Dulai GS, Guha S, Kahn KL, Gornbein J, Weinstein WM. Preoperative 65 years, for example, were nearly 7-fold more likely to have prevalence of Barrett’s esophagus in esophageal adenocarcinoma: a systematic BE or esophageal cancer compared with a cohort of women review. Gastroenterology. 2002;122(1):26-33. younger than 50 years as the reference group, but these men 10. Chang JY, Locke GR III, McNally MA, et al. Impact of functional were also significantly less likely to undergo EGD (odds ratio, gastrointestinal disorders on survival in the community. Am J Gastroenterol. 0.77).8 2010;105(4):822-832. We still miss most patients with BE despite the wide- spread use of EGD; up to 95% of cases of adenocarcinoma occur in the setting of no prior diagnosis of BE.9 The data from Kramer et al8 suggest that this may in part be due to Physicians’ Preferences for Hospice if They Were underutilization of EGD in high-risk cases. On the other Terminally Ill and the Timing of Hospice Discussions hand, the mortality of symptomatic reflux is not increased With Their Patients over the background population,10 and there is still no con- Physicians often delay hospice discussions with their termi- vincing evidence that endoscopic screening of symptomatic nally ill patients despite guidelines recommending such dis- GERD will reduce esophageal adenocarcinoma rates (stop- cussions for patients expected to die within 1 year,1,2 but ping smoking and losing weight would probably be more reasons for this are not well understood. Evidence suggests valuable).3 Until noninvasive biomarkers to identify BE are that physicians “practice what they preach” when counsel- available, judicious application of EGD to those with alarm ing about health behaviors,3 although their treatment rec- signals or other high-risk cases (eg, those with chronic ommendations may not necessarily reflect their own prefer- heartburn, who are older white men, or those with chronic ences, with one study suggesting they recommend more reflux who are obese) seems reasonable but is unlikely to conservative treatments than they might choose for save many lives. themselves.4 As physicians may prefer less aggressive end- of-life care than their patients generally receive,5 physi- cians’ personal preferences for hospice may influence their Nicholas J. Talley, MD, PhD, FRACP approach to hospice discussions with their terminally ill Kate E. Napthali, FRACP patients. We examined physicians’ reported preferences for hos- Author Affiliations: University of Newcastle, Newcastle, New South Wales, pice enrollment if they were terminally ill. We also assessed Australia (Talley); John Hunter Hospital, Newcastle, New South Wales, Australia (Napthali); Mayo Clinic, Rochester, Minnesota (Talley). whether physicians who would enroll in hospice if terminally Corresponding Author: Nicholas J. Talley, MD, PhD, FRACP, University of ill differed from others in the timing of hospice discussions with Newcastle, Callaghan, NSW 2308, Australia ([email protected]). their patients. Published Online: January 27, 2014. doi:10.1001/jamainternmed.2013.12992. Methods | This study was approved by the institutional review Conflict of Interest Disclosures: None reported. boards at all participating institutions. We surveyed physi- 1. Evans JA, Early DS, Fukami N, et al; ASGE Standards of Practice Committee; cians caring for patients with cancer enrolled in the multire- Standards of Practice Committee of the American Society for Gastrointestinal gional population-based Cancer Care Outcomes Research and Endoscopy. The role of endoscopy in Barrett’s esophagus and other 1 premalignant conditions of the esophagus. Gastrointest Endosc. Surveillance (CanCORS) study. Informed consent was im- 2012;76(6):1087-1094. plied by physicians’ participation in the survey. Physicians in- 2. Solaymani-Dodaran M, Logan RF, West J, Card T, Coupland C. Risk of dicated on a 5-point Likert scale how strongly they agreed or oesophageal cancer in Barrett’s oesophagus and gastro-oesophageal reflux. disagreed with the statement “If I were terminally ill with can- Gut. 2004;53(8):1070-1074. cer, I would enroll in hospice.” They were also asked to as- 3. Kahrilas PJ, Shaheen NJ, Vaezi MF; American Gastroenterological Association sume that they were caring for an asymptomatic patient with Institute; Clinical Practice and Quality Management Committee. American Gastroenterological Association Institute technical review on the management advanced cancer, who they believed had 4 to 6 months to live of gastroesophageal reflux disease. Gastroenterology. 2008;135(4):1392-1413. and report whether they would discuss hospice with the pa- 4. Shaheen NJ, Weinberg DS, Denberg TD, Chou R, Qaseem A, Shekelle P; tient “now,” “when the patient first develops symptoms,” Clinical Guidelines Committee of the American College of Physicians. Upper “when there are no more nonpalliative treatments to offer,” endoscopy for gastroesophageal reflux disease: best practice advice from the “only if the patient is admitted to the hospital,”or “only if the clinical guidelines committee of the American College of Physicians. Ann Intern 1 Med. 2012;157(11):808-816. patient and/or family bring it up.” 5. Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management Among 4488 respondents (response rate 61%), we ex- of gastroesophageal reflux disease. Am J Gastroenterol. 2013;108(3):308-328. cluded 105 who did not answer the hospice self-preference 466 JAMA Internal Medicine March 2014 Volume 174, Number 3 jamainternalmedicine.com Copyright 2014 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 Letters Table. Physician Willingness to Enroll in Hospice: Personal and Practice Characteristicsa Unadjusted Proportion Who Strongly Agree They Would Enroll in Hospice if Strongly Agreeing They Terminally Ill With Cancer, Would Enroll in Hospice, Physician Characteristics Total, No. (%) % Adjusted OR (95% CI)b Total 4368 (100) 64.5 Age, y ≤39 959 (22) 65.4 1 [Reference] 40-49 1264 (29) 65.5 1.08 (0.89-1.31) 50-54 767 (18) 67.1 1.18 (0.95-1.47) 55-59 702 (16) 65.4 1.20 (0.96-1.50) ≥60 676 (15) 57.7 1.00 (0.79-1.25) Sex Abbreviation: OR, odds ratio. Male 3453 (80) 61.9 1 [Reference] a Percentages include only reported, Female 837 (20) 76.1 1.80 (1.49-2.18) nonimputed values and may not sum to 100% because of rounding Specialty or missing values. Missing values Primary care physician 1743 (41) 69.5 1 [Reference] were present for the following Surgery 923 (22) 56.6 0.65 (0.55-0.78) variables: sex (n = 78), specialty (n = 77), proportion of patients in Medical oncology 600 (14) 70.3 0.93 (0.74-1.17) managed care (n = 374), and Radiation oncology 257 (6) 57.6 0.57 (0.42-0.76) number of terminally ill patients Other specialty 768 (18) 61.2 0.75 (0.62-0.90) cared for in the past year (n = 62). Adjusted analyses used imputed Patients in managed care, % data. ≤50 2330 (58) 60.8 1 [Reference] b Adjusting for all variables in the ≥51 1664 (42) 69.8 1.30 (1.12-1.51) table, as well as type of practice. No. of terminally-ill patients Board certification, US medical in the last year school graduate status, and level of ≤12 2308 (54) 62.5 1 [Reference] teaching involvement were not associated in adjusted analyses and ≥13 1998 (46) 67.1 1.29 (1.12-1.50) were not included in the model. hospice “now” with their terminally ill patients. We omitted Figure. Physician Willingness to Enroll in Hospice and Report of Early Hospice Discussions With Terminally Ill Patients With Cancer variables with adjusted P values >.10. 35 Results | Respondents’ characteristics are given in the Table. Most respondents strongly (64.5%) or somewhat (21.4%) 30 agreed they would enroll in hospice if terminally ill. In 25 adjusted analyses, physicians who were female, cared for more terminally ill patients, and worked in managed-care 20 settings were more likely than others to strongly agree they 15 would enroll in hospice. Surgeons and radiation oncologists were less likely than primary care physicians to strongly 10 Discuss Hospice “Now,” % Discuss Hospice “Now,” agree they would enroll in hospice. Adjusted Proportion Who Would 5 Overall, 26.5% reported they would discuss hospice “now” with a patient who had 4 to 6 months to live. Other 0 Strongly agree Other responses physicians reported they would wait until the patient has Personal Preferences for Hospice symptoms (16.4%), there were no more treatments to offer Enrollment if Terminally Ill (48.7%), the patient and/or family brings it up (4.3%), or the patient is hospitalized (4.1%).
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